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'SEP-6-2013 0`3:31 FPO 1:H -12C�19A6311 ) r.t•i <br /> RECEIVED <br /> Affor ..`�'�i # 416 2"Street Phone:(209)744.0112 SEP 1 6 2 13 <br /> GVic,Ca 95632 fax.(204)744-0116 <br /> aford sofirom.act rAL <br /> Owner Stattments of Designated Underground Storagt: Tank Operator <br /> and Under%tunding of and Coen hunce with UST Requirements "'l Jc:✓'ARlMENT <br /> FRc11iry NO Me: t tro--o Facility 0: POO <br /> Addrea9: (I /y (+ Updatcaf Owners Statement <br /> F111Cittty P OL11C tL--/ ) CAangr of AteiGrstrd Owster <br /> Q hew DaIrnnted Operator <br /> DXh%gMj.ED ST 0-FJFRAJOR FOR T_WS V?ACILI'FV: <br /> PRIMARY <br /> Dtt ynetcd OpersMr't Name', LANP NtMMO Serviee'reeLo:etsn <br /> lloiinel Cama AFFORDA TEST ICC p: SW)2l-UC <br /> Deslgnsm Opetator't rwitt: 207-144-0t12 Erptratine Atte: Y2114 <br /> ALTERNAT'L 1 <br /> txtdg tetai Ops vror's Name: FELIX ItAtMIKU Service'I'mhoicisn <br /> 0esb'e0Name: AFFORDA TEST ICC a: 527)3934.t1C <br /> DedgamedOtreretpr's Phoney 2W144-Ot12 6spirrtttus Uste: 3/L11 <br /> ALTERNATC z <br /> t)eslltaetrdOperttsr's"+0rne: DAVID*I*VINKLER Serviet Terhnkian <br /> tlustotw Name: AFFORDA TEST AM N: c2Q3'13-t;C <br /> Dwannttd Operotw's Phone 709-744.0112 Espiradaa hate: 3444 <br /> ALTERNATE 3 <br /> UrslgaaWl Operator's r4aeic: LYLE NI.M ^iO 3errietyat'tleititta <br /> rasinrrt Name: AFF'ORUA TEST ICC r: 5249111-IIC <br /> DetiU%otro Orereim's t'►une: X14-74.1-01112 Espsraauu that: 3W4 <br /> ALTERNATE 4 <br /> t)csiptotrd Urcret,tr's Names CrYwAkO S TARNS swevice`reef,4,1110 <br /> &$ono"game: A2►FORDA'r FAT ICC x S24d492-UC <br /> Ues,tuetid OFervUw't rttoat: 2U9-704-0112 Espirativa rioter 12/29/14 <br /> 1 Ccrtif)thlt,for 1111e U11011ty indicated at the top of this papo,the Individuals li37td above will serve at DesiCnatcd UST <br /> Chw4tars. flit Individuals will conduct and document monthly faellity Inspections and annuaa faCility empitsyee <br /> train Ing,In <br /> Accordance with Callfernla Code of krjulationo,title 23,soction 1715(a►�It1r <br /> Fttithormom I understand mid am in compliance with the requircment (watolta.t'ceulailont.and ',ocol <br /> Ordinenco) apylirst4le to underground storage bnkt:. <br /> NAME OF TANK OWNER/Operator(Print): <br /> SIGNATURE OF TANKNE perotar: <br /> DATE: Z6 3 tOWN XRS FEIC? 6-sZ' <br /> NOTE: <br /> 1) Sit i4'KET T141S COMPL6 FED FOMM TO THE LOCAL AGFNCY(NOT SWRCD)AF TF.R StAghiro;,TM LOCA L <br /> AGENCY LIST 18 AVAII.AVU AT: !t tc .n,tuett'cuna �:.Ittntl. <br /> 21 NU'r[FYT4U LOCAL AGENCY OV AV`s'CIMS F.TOTMItI iNFORMA't`It()iV WITHIN]0 DAYS OFTIM <br /> CIANG& <br /> OFFICE: <br /> County: ' Cotte Posed: Drat Scanned; <br /> - �` Detc &:►tails+! <br />